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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601026
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:30:13 PM

Document Has Been Signed on 11/17/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:EARLY HORIZONS HOME CAREFACILITY NUMBER:
415601026
ADMINISTRATOR:ROGAYAN, YOLANDAFACILITY TYPE:
740
ADDRESS:2800 SHANNON DRTELEPHONE:
(650) 255-5418
CITY:S SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 4DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Licensee, Yolanda RogayanTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Yolanda Rogayan. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA initiated a walk-through of the facility around 12:20pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had a mask on during this visit. Commonly touched surfaces are disinfected once per day. Facility maintains documentation of staff and resident daily temperatures. LPA was not screened upon entry but did confirm that Licensee had a thermometer and a sign in log for visitors. LPA reviewed the visitor log.

During inspection LPA observed that an area of the dining room has been sectioned off with a temporary half wall. Area is used for an office and Licensee admitted that staff also use the area for sleeping. LPA told Licensee that common areas may not be used for sleeping. LPA will reach out to the San Bruno Licensing Office to address further steps.

Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) but have not been N95 fit tested.

Facility has at least a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: EARLY HORIZONS HOME CARE
FACILITY NUMBER: 415601026
VISIT DATE: 11/17/2022
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Continued from LIC809

Licensee and LPA discussed their Emergency Disaster Plan and Mitigation Plan. Facility has not completed their Infection Control Plan.



Licensee/Administrator to submit updates of the following documents to the San Bruno Licensing Office by 12/16/2022:

Infection Control Plan with Monkey Pox Addendum
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update)
Copy of Liability Insurance

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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